Scholarly Commons @ Baystate Health
Not a member yet
8474 research outputs found
Sort by
Ascorbate for Organ Dysfunction in Critically Ill Patients With Sepsis: The Phase 2b ASTER Trial
No full textBackground: A phase 2 trial of high-dose IV ascorbate suggested reduced mortality in patients with ARDS, although trials in sepsis have failed to show clinical benefit.
Research question: Does IV high-dose ascorbate improve outcomes in patients with sepsis at risk of or with ARDS?
Study design and methods: In this phase 2b multicenter randomized placebo-controlled trial, patients with known or suspected infection and either shock or acute hypoxemic respiratory failure were randomized to ascorbate (50 mg/kg IV every 6 hours for 5 days) or a matching placebo. The primary outcome was days alive and free of respiratory, renal, and circulatory organ support to day 28. Secondary outcomes included clinical and biological end points.
Results: After enrolling 79 participants, the trial was terminated because of the publication of a separate study of septic shock reporting increased mortality with ascorbate. In the current study, days free of organ support were not different for patients receiving ascorbate compared with those receiving placebo: mean (SD), 20.5 (9.5) days vs 19.0 (10.8) days, respectively (P = .528). The 90-day all-cause mortality was 15% in the ascorbate group vs 33% in the placebo group (P = .057). This was 1 of 19 secondary end points. Soluble tumor necrosis factor receptor 1 levels were reduced in the ascorbate group vs placebo from baseline to both day 2 (median, -861 pg/mL [interquartile range (IQR), -3,043 to 128.9 pg/mL] vs 241.4 pg/mL [-820 to 1,671 pg/mL]; P = .005) and day 3 (median, -1,511 pg/mL [IQR, -2,636 to -36.3 pg/mL] vs -131 pg/mL [-986 to 2,202 pg/mL]; P = .008).
Interpretation: Ascorbate did not improve days free of organ failure, although no safety concerns were identified in this small study. Ascorbate was shown to reduce a biological marker of inflammation associated with adverse outcomes in sepsis and lung injury.
Keywords: antioxidant; lung injury; vitamin C
Outcomes of aortic stenosis in patients with cardiac amyloidosis: A systematic review and meta-analysis
No full textBackground: Cardiac amyloidosis (CA) results from the deposition of abnormally folded protein fibrils, leading to restrictive cardiomyopathy, valvular heart disease, and arrhythmias. Up to 15 % of patients with severe aortic stenosis (AS) have concomitant CA (AS-CA). We conducted this systematic review and meta-analysis to compare medical management, transcatheter aortic valve replacement (TAVR), and surgical AVR (SAVR) in AS-CA.
Methods: A comprehensive literature search was conducted for relevant studies from inception through January 20, 2024. Studies exploring outcomes in adult AS patients with and without CA receiving medical therapy, TAVR, or SAVR were included in this analysis.
Results: Fifteen studies including 253,334 patients (AS-CA 6704; AS alone 246,630) were identified. AS-CA patients had significantly higher all-cause mortality (RR = 2.60, 95 % CI 1.48-4.57, P = 0.0009) compared to AS alone. Among patients with AS-CA, TAVR was associated with lower all-cause mortality compared to both medical therapy (RR = 0.50, 95 % CI 0.29-0.89, P = 0.02) and SAVR (RR = 0.41, 95 % CI 0.22-0.78, P = 0.007). AS-CA patients undergoing TAVR were more likely to have paradoxical low-flow, low-gradient AS (RR = 1.56, 95 % CI 1.15-2.12, P = 0.04) at baseline and had a higher risk of post-TAVR acute kidney injury (RR = 1.95, 95 % CI 1.35-2.80, P = 0.0003) compared to patients undergoing TAVR for AS alone. There were similar risks of other post-TAVR complications, including major bleeding, vascular complications, stroke, and new pacemaker implantation between AS-CA and AS alone.
Conclusion: CA is associated with a higher mortality in patients with severe AS. In patients with concomitant AS and CA, TAVR is safe and associated with better survival than medical therapy or SAVR. SOCIAL MEDIA ABSTRACT: #Meta-Analysis: Cardiac amyloidosis is associated with increased mortality in severe AS. #TAVR is safe in amyloidosis & improves survival more than medical therapy or SAVR.
Keywords: Aortic stenosis (AS); Cardiac amyloidosis (CA); Meta-analysis; Mortality; Surgical aortic valve replacement (SAVR); Transcatheter aortic valve replacement (TAVR)
Influence of insurance type on healthcare utilization among rural people who use drugs
No full textBackground: Insurance possession facilitates healthcare engagement. Though people who use drugs (PWUD) experience substantial health risks, a large proportion are un/underinsured. Medicaid/other insurance eligibility varies by state and criminal legal involvement (CLI), and a better understanding of their association is important to inform policy.
Methods: Participants in the Rural Opioid Initiative were recruited 2018-2020 across 10 states and completed surveys assessing their demographics and insurance status, CLI experiences, substance use-related healthcare utilization, and healthcare barriers and venues. Descriptive analyses examined these factors versus insurance status and were followed by multivariable regression to include Medicaid expansion state residence.
Results: The 2933 participants had a mean age of 36 years [s.d.= 10.3]; were 85 % White, 3.2 % Black, and 7.1 % Native American; and were 57.0 % men. Insurance status was categorized as none (23.9 %), Medicaid (60.0 %), and other (16.2 %). Reporting stop/search, arrest or jail correlated with a significant reduction in the proportion of persons with Medicaid insurance (all p \u3c 0.001). Having ever received HCV/HIV screening, and eight types of substance use disorder treatment, were more common among Medicaid versus uninsured individuals (p ≤ 0.001). Medicaid insured individuals more frequently reported obtaining care at a private venue, and less frequently reported having no care (past 6-months) or care barriers (p \u3c 0.001) CONCLUSION: Lack of insurance among rural PWUD was associated with CLI, reduced healthcare utilization, and greater care barriers. Medicaid coverage facilitates national-level guideline promulgation regarding healthcare access of individuals experiencing increased health risks. Links between Medicaid expansion and CLI indicate opportunities to better coordinate services.
Keywords: Criminal legal involvement; Healthcare; Insurance status; People who use drugs; Rural
Moyamoya Disease- A Clinical Mimic for Psychiatric Disorders in the Emergency Setting: A Case Report
No full textPatient presentations to the emergency department for mental health evaluations are common, with an estimated 1 in 4 adult visits made for this reason. These presentations are often accompanied by vague symptomatology, which may make it difficult to determine if they are because of another medical condition. Previous evaluations may bias future presentations, leading to premature closure before correctly identifying a causative underlying medical condition. Accurate, timely diagnosis improves health care costs by decreasing inappropriate treatments and unnecessary admissions and lowering the risk of recidivism. A 32-year-old woman presented with a complaint of recurrent neuropsychological symptoms attributed incorrectly to a primary mental disorder. On representation, she was found on computed tomography angiogram imaging to have pathognomonic findings for moyamoya disease. A short review of neuropsychological presentations previously attributed to moyamoya disease is reviewed. Because of the frequency with which we encounter patients for a mental health evaluation and the multifaceted harms of misdiagnosis, emergency providers should be familiar with moyamoya disease as a cause of mental disorders due to another medical condition.
Keywords: cerebrovascular accident; moyamoya, medical mimic; secondary psychosis; stroke
The History of the New Jersey Salvati-Rubin Colon and Rectal Surgery Residency (Rutgers, Robert Wood Johnson Medical School)
No full textRight ventricular dysfunction as a mortality determinant for patients with cardiogenic shock induced by acute myocardial infarction
No full textBackground: Cardiogenic shock (CS) secondary to acute myocardial infarction (AMI) is a major cause of in-hospital mortality. With the addition of right ventricular dysfunction (RVD), it is associated with poorer outcomes. This study examines the impact of RVD on mortality in CS-AMI patients, highlighting the importance of early RVD identification and tailored management.
Methods: Data from the Gulf Cardiogenic Shock (Gulf-CS) registry-a multicenter registry of CS-AMI patients from six Gulf countries-were analyzed to compare in-hospital and long-term outcomes for patients with and without RVD. RVD was defined by echocardiographic criteria: TAPSE \u3c17 mm, S\u27 wave \u3c12 cm/s, and TAPSE/PASP ratio \u3c 0.34. Multivariable logistic and Cox regression models were used to identify in-hospital and follow-up mortality predictors.
Results: Among 1,513 CS-AMI patients, RVD was independently associated with higher in-hospital mortality (55.87% vs. 42.89%, p \u3c 0.001) and lower survival at 6, 12, 18, and 24 months (58%, 35%, 18%, and 6% vs. 73%, 53%, 38%, and 30%; p \u3c 0.001). Predictors of in-hospital mortality included advanced SCAI shock stage, cardiac arrest, age, NSTEMI, number of vessels affected, and elevated creatinine, while follow-up mortality was associated with advanced SCAI stage, reduced LVEF, elevated BUN, history of CABG and comorbidities including COPD and prior CVA.
Conclusion: RVD is a significant independent predictor of both in-hospital and long-term mortality in CS-AMI, highlighting the need for early RVD assessment and specific interventions. This study\u27s findings support the integration of RV-focused management strategies to improve survival outcomes in this high-risk population
Preemptive anticoagulation during antenatal pulmonary embolism diagnostics in a community setting: retrospective cohort study
No full textBackground: Society recommendations for preemptive (or empiric) anticoagulation during antenatal pulmonary embolism (PE) diagnostics rely on expert opinion, which varies widely across guidelines. The American College of Chest Physicians (CHEST), for example, recommends preemptive anticoagulation when PE is highly suspected or when a delay in imaging is anticipated. The American College of Obstetricians and Gynecologists, however, makes no mention of preemptive anticoagulation for suspected PE in their practice bulletin on thromboembolism in pregnancy. Patterns of preemptive anticoagulation in pregnancy are unknown.
Objectives: To describe the prevalence of and CHEST-based eligibility for preemptive anticoagulation in pregnancy.
Methods: This retrospective cohort study was undertaken across 21 United States community hospitals from October 1, 2021 through March 30, 2023. We included pregnant adults without COVID-19 undergoing definitive diagnostic PE imaging. We used pregnancy-adapted Geneva scores to calculate pretest probability as a proxy for suspicion.
Results: We included 326 patients: median age, 31.0 years; 51% were in the third trimester. Diagnostic settings included emergency departments (n = 254; 78%), Labor & Delivery (n = 65; 20%), and outpatient clinics (n = 7; 2%). Median time from emergency department computed tomography order to results was 1.40 hours (IQR: 0.78, 2.06). Prevalence of confirmed or presumed PE was low (n = 8; 2.5%). Only 2 patients (0.6%) received preemptive anticoagulation, whereas by CHEST criteria, 34 patients (10.4%) were eligible.
Conclusion: We found rare use of preemptive anticoagulation during antenatal PE diagnostics in this imaged cohort with low PE prevalence and rapid access to diagnostic imaging. More research is needed to explore setting-specific variation in preemptive anticoagulation use.
Keywords: anticoagulants; computed tomography angiography; perfusion imaging; pregnancy; pulmonary embolism
Words matter: Destigmatizing the language of medicine through research, training, and future directions for emergency medicine
No full textBackground: In emergency medicine (EM), language choice significantly impacts patient care and can potentially cause harm, dehumanize patients, and introduce bias. Stigmatizing language in medical settings can affect patient dignity, trust, and outcomes. Despite its importance, there is limited education on avoiding stigmatizing language in EM. This concept paper addresses the need to raise awareness and develop strategies for use of inclusive language in the emergency department (ED).
Methods: A didactic session titled Words Matter: Destigmatizing the Language of Medicine was developed and presented at the 2024 Society for Academic Emergency Medicine (SAEM) Annual Meeting. The session involved a collaborative team of 12 individuals, including an EM resident, health equity fellow, and EM faculty. Content creation involved a comprehensive literature review and consensus-based decision making. The session featured current research related to stigmatizing language and interactive components, including case-based discussions and equity-focused alternative language choices.
Results: The didactic session, attended by approximately 70 participants, successfully highlighted the impact of stigmatizing language on health care disparities and patient trust. Interactive case studies allowed participants to identify and propose alternatives to stigmatizing language. The session provided actionable strategies for integrating inclusive language into practice and education. Postdidactic discussions emphasized the need for ongoing research and specific educational interventions to address stigmatizing language in EM.
Conclusions: Addressing stigmatizing language in EM is crucial for providing equitable and respectful patient care. The didactic session demonstrated effective methods for raising awareness and training health care professionals in using inclusive language. Future efforts should focus on developing standardized approaches for identifying and mitigating stigmatizing language, integrating these practices into training programs, and conducting longitudinal research to assess the impact on patient outcomes. Creating a culture of inclusive language in the ED will contribute to improved patient trust and care quality
Innovation, Wellness, and EBP Cultures Are Associated With Less Burnout, Better Mental Health, and Higher Job Satisfaction in Nurses and the Healthcare Workforce
No full textBackground: Staff shortages as well as poor nurse and clinician well-being are currently an epidemic within the health workforce and pose a substantial risk to healthcare quality and safety. Creating a strong wellness culture is one strategy to address the issue, but there is a paucity of research that investigates how other types of organizational cultures are related to nurses\u27 mental health and well-being.
Aims: To describe the relationships among innovation culture, wellness culture, evidence-based practice (EBP) culture, and clinician well-being (healthy lifestyle behaviors, burnout, depression, stress, anxiety, and job satisfaction).
Methods: A cross-sectional descriptive correlational study design was used with a convenience sample of nurses, physicians, and allied health professionals from a Magnet-recognized health system in the United States. An online wellness survey collected data with the variables of interest using valid and reliable scales. Pearson\u27s r correlations assessed the relationship among innovation culture, wellness culture, and EBP culture. A series of regressions examined if each type of culture was associated with clinician well-being.
Results: The analytic sample included 199 respondents. Innovation culture had a strong and significant correlation (p ≤ 0.0001, r \u3e 0.7) with both clinician well-being and EBP cultures. Wellness and EBP cultures also were correlated (p ≤ 0.0001, r = 0.592). Higher ratings of each type of culture were significantly associated with higher job satisfaction as well as higher ratings of both mental and physical health. Further, higher ratings on each culture scale were significantly associated with reduced stress, anxiety, depression, burnout, and job satisfaction.
Linking evidence to action: This is the first study to establish correlations among innovation culture, EBP culture, and wellness culture as well as to find that these three types of cultures are associated with clinician well-being outcomes and job satisfaction. Since culture strongly impacts the healthcare workforce\u27s mental health and job satisfaction, leaders need to focus on an organizational-wide strategic approach that builds a sustained culture that supports clinician well-being, innovation, and EBP.
Keywords: burnout; innovation; job satisfaction; nursing; work culture
Enhancing Fall Risk Assessment: The Development of Nursing Education on the Modified Dionne’s Egress Test on a Medical Geriatric Unit
No full textBackground:
Geriatric falls are common and dangerous. Fall risk screening is one important element to a comprehensive fall reduction program. Local Problem:
A geriatric inpatient unit in Massachusetts faced high fall rates. Established fall risk screening did not incorporate mobility assessment. Methods:
This pre-post study explored staff experience, engagement, compliance, and scoring accuracy with implementation of the Modified Dionne’s Egress Test (MDET). Data were collected using staff surveys, training rosters, practice assessments, and tracking sheets. Data were analyzed using descriptive statistics. Interventions:
Staff were educated using a clinical pathway tool, in-person training, and reference materials. MDET implementation occurred over 6 months, beginning April 2023. Results:
Pre-intervention, staff largely viewed the MDET favorably. Post-intervention surveys revealed declining satisfaction. Staff demonstrated low training engagement (24%), low compliance (16%), and moderate scoring accuracy (75%). Conclusion:
Within geriatric units, MDET implementation faces significant challenges. More work is needed to support routine patient mobility assessment